Hindawi

Journal of Healthcare Engineering

Volume 2021, Article ID 9947255, 8 pages
https://doi.org/10.1155/2021/9947255

Research Article
Clinical Effects of Form-Based Management of Forceps
Delivery under Intelligent Medical Model

Siming Xin , Zhizhong Wang , Hua Lai , Lingzhi Liu , Ting Shen ,
Fangping Xu , Xiaoming Zeng , and Jiusheng Zheng
Department of Obstetrics, Maternal and Child Health Hospital Affiliated to Nanchang University, Nanchang 330006,
Jiangxi, China

Correspondence should be addressed to Xiaoming Zeng; 18070038675@163.com and Jiusheng Zheng; zjsheng2012@sina.com

Received 12 April 2021; Revised 13 May 2021; Accepted 20 May 2021; Published 31 May 2021

Academic Editor: Han Wang

Copyright © 2021 Siming Xin et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Forceps delivery is one of the most important measures to facilitate vaginal delivery. It can reduce the rate of first cesarean
delivery. Frustratingly, adverse maternal and neonatal outcomes associated with forceps delivery have been frequently reported in recent
years. There are two major reasons: one is that the abilities of doctors and midwives in forceps delivery vary from hospital to hospital and
the other one is lack of regulations in the management of forceps delivery. In order to improve the success rate of forceps delivery and
reduce the incidence of maternal and neonatal complications, we applied form-based management to forceps delivery under an
intelligent medical model. The aim of this work is to explore the clinical effects of form-based management of forceps delivery. Methods.
Patients with forceps delivery in Maternal and Child Health Hospital Affiliated to Nanchang University were divided into two groups:
form-based patients from January 1, 2019, to December 31, 2020, were selected as the study group, while traditional protocol patients
from January 1, 2017, to December 31, 2018, were chosen as the control group. Then, we compared the maternal and neonatal outcomes
of these two groups. Results. There were significant differences in the maternal and neonatal adverse outcomes such as rate of postpartum
hemorrhage, degree of perineal laceration, and incidence of neonatal facial skin abrasions between the two groups, whereas differences in
the incidence of asphyxia and intracranial hemorrhage were not significant. Conclusions. Form-based management could help us assess
the security of forceps delivery comprehensively, as it could not only improve the success rate of the one-time forceps traction scheme
but also reduce the incidence of maternal and neonatal adverse outcomes effectively.

1. Introduction medical works for reducing the morbidity of perinatal

During the information era, medical and health field was
gradually moving towards informationization and intellec-
tualization. The intelligent medicine was a cross-discipline
on the integration of life science and information tech-
nology, and it was a new stage of information construction in
the healthcare field. By using information management,
patients’ clinical data could be fully recorded and tell us
more about the situation of patients, which could help us to
design effective treatments.
Under the environment of high cesarean section rate, we
have the responsibility to promote vaginal birth and reduce
primary cesarean birth rate [1, 2]. In order to obtain this
goal, we need to put intelligent medicine into our daily
pregnant women and newborns. Through this way, we could
reduce the evaluation errors caused by differences in clinical
experience and other factors, so as to reduce the incidence of
perinatal pregnant women and newborns [3]. In recent
years, intelligent medicine has been widely used in prenatal
fetal heart monitoring [4, 5], vaginal trial delivery model
prediction after cesarean section [6], prediction model of
vaginal birth after cesarean, and premature delivery [7]. It
also has been used in postpartum hemorrhage prediction
[8, 9]. During the time, it has achieved fairly good results in
vaginal midwifery training [10].
Vaginal forceps delivery, one of the surgical vaginal
methods, could resolve cephalic dystocia effectively, for ex-
ample, maternal exhaustion, maternal cardiac disease and
2 Journal of Healthcare Engineering
a need to avoid pushing in the second stage of labor, prolonged
second stage of labor, and nonreassuring fetal heart rate patterns
in the second stage of labor [11]. Under these conditions,
forceps delivery could be accomplished more safely and quickly
than cesarean. Therefore, the skill of forceps delivery was one of
the most important clinical skills required for obstetricians and
midwives [12]. Of course, forceps delivery not only requires the
above skill but also needs accurate judgment and systematic
evaluation of the patient’s condition in advance. In recent
decades, severe laceration of the birth canal, postpartum
hemorrhage, and neonatal injury caused by forceps delivery
have been constantly reported [13, 14]. Our hospital began the
construction of an intelligent hospital in 2018 and has suc-
cessively introduced information systems such as integrated
platform, HIS, LIS, and HRP. Relying on these information
platforms, we were able to implement form-based management
of forceps delivery since January 1, 2019. In order to explore the
effectiveness of form-based management of forceps delivery in
improving the success rate of forceps delivery and reducing the
incidence of adverse maternal and fetal outcomes, we were
reviewing and analyzing the maternal and infant outcomes of
patients with forceps delivery in our hospital during the period
from January 1, 2017, to December 31, 2020.
2. Materials and Methods
2.1. Study Population. This retrospective cohort study was
conducted at the Maternal and Child Health Hospital Affil-
iated to Nanchang University. The study population consisted
of pregnant women who underwent forceps delivery from
January 1, 2017, to December 31, 2020. Cases with forceps
delivery managed by form-based management from January
1, 2019, to December 31, 2020, were established as the study
group, and cases with forceps delivery managed by traditional
protocol from January 1, 2017, to December 31, 2018, were
established as the control group. The inclusion criteria were as
follows: single full-term fetus, fetal position being cephalic
position, indications for forceps delivery being prolonged
second stage of labor or suspicion of immediate fetal distress
or maternal complications, and low forceps with Kielland or
Simpson forceps. The position of the fetal head in low forceps
was that the lowest point of fetal cranial mass was located at or
below +3 cm but it did not reach the pelvic floor. The ex-
clusion criteria were huge babies and scarred uterus. The labor
process in this study adopted new labor process standards
[15]. Eligible women were identified from the hospital data
management system, and all study participants were informed
of the risks associated with forceps delivery and signed an
informed consent form before undergoing forceps delivery.
2.2. Clinical Data Collection. Our hospital has introduced
a medical record information system and medical record
management system. Information between these two sys-
tems was completely interoperable. All medical records in
this study were retrieved through the medical record
management system. The retrieval strategy was: low forceps
delivery as the procedure code, procedure time of January 1,
2019, to December 31, 2020, for the study group and January
1, 2017, to December 31, 2018, for the control group, the
discharge code was singleton live birth. The delivery data was
entered into the hospital data management system imme-
diately after delivery by the midwives responsible for the
ongoing care of the woman. Maternal data included age,
height, weight, gravidity, parity, gestational age, indication
of forceps delivery, instrument used, estimated blood loss,
and degree of perineal laceration. Newborn data included
birth weight, Apgar scores, umbilical artery blood pH value,
intracranial hemorrhage, and facial skin injury.
3. Form-Based Forceps Delivery
Management Program
From January 1, 2019, to December 31, 2020, we used form-
based management of vaginal forceps delivery including
a delivery room safe delivery verification form (Table 1) and
a forceps delivery verification form (Table 2), which was
verified by senior physicians, resident physicians, and
midwives to systematically standardize forceps operations
with the following steps. In particular, the senior doctors and
midwives who were allowed to participate in this study
should have the following qualifications: senior doctors
should have intermediate or above titles, have at least 2 years
of work experience in the delivery room, have passed the
hospital assessment, and have been authorized the forceps
midwifery technique while midwives were senior aided birth
attendants with no less than 5-year midwifery experience.
3.1. Preoperative Verification. Prior to forceps imple-
mentation, residents reported to the senior physician about
the progress of delivery, previous history, the ultrasound
results in details, and the current dilemma. Then, the senior
physician checked the delivery safety checklist (Table 1) and
performed an abdominal examination to reestimate the fetal
size and fetal lie, then clarified the fetal station, fetal head
descent, and the clinical adequacy of the maternal pelvis by
vaginal examination. A discussion was taken among the
senior physician, residents, and midwives to determine
whether the forceps assisted delivery was reasonable or not,
and then an appropriate type of forceps would be selected as
a result. The selection criteria of forceps were as following:
Simpson forceps were selected when the fetal position was
the anterior occipital position or nonoccipital position
turned into anterior occipital position by hand, whereas
Kielland forceps were selected when the fetal position was
transverse and hand rotation fails. Then, the first part of the
forceps delivery checklist (Table 2) would be completed.
3.2. Preoperative Preparation. After the verification work is
finished, the senior physician would tell the pregnant
woman and her guardian the necessity and risks of forceps
delivery and then indicate them to sign an informed consent
form. Meanwhile, the residents and midwives completed the
preparation of the midwifery kit, forceps, and neonatal
asphyxia resuscitation equipment and completed the second
part of the forceps assisted delivery verification form
(Table 2).
Journal of Healthcare Engineering 3

Table 1: The delivery room safe delivery verification form.

4 Journal of Healthcare Engineering

Table 2: The forceps delivery verification form.

Journal of Healthcare Engineering
3.3. Intraoperative Verification. To ensure bladder empty
and adequate analgesia, if necessary, a lateral perineal
incision would be recommended. The senior physician
should reconfirm the fetal position that was occipi-
toanterior by vaginal examination. If it was posterior or
transverse occipital, Sb should transfer them into ante-
rior by manually rotating the fetal head between con-
tractions. Once the rotation failed, Kielland forceps were
used to rotate the fetal head into an occipitoanterior
position.
3.3.1. Operations of Kielland Forceps. Placing forceps on
both sides of the fetal head by the one-handed forceps
method, then the operator clamped forceps after confirming
no soft tissues of the birth canal were clamped. After
reconfirming the correct position of the forceps, the operator
took a standing position, with the index and middle fingers
placed on the two shoulders of the forceps, and then pulled
the forceps along the pelvic axis. In the first place, the di-
rection of downward and outward traction was at an angle of
30 degrees below the horizontal plane. As the fetal head was
gradually delivered, the handle of the forceps was slowly
lifted. When the fetal head was exposed, the direction of
traction was changed to horizontal, and the forceps were
removed when the fetal head was pulled to the crown. The
midwife continued to assist in the delivery of the fetal head
and carcass.
3.3.2. Operations of Simpson Forceps. Doctor’s posture and
the traction direction of Simpson forceps were the same as
Kielland forceps, while the difference was that in an oper-
ation of Simpson forceps when the vaginal opening exposed
the forehead of the fetus, the handle of the forceps was
gradually lifted up to help the fetal head stretch up. When
the mandible of the fetus could be touched, the forceps
would be removed, and the midwife continued to deliver the
fetal head and carcass.
3.4. Postoperative Verification. Once the baby was born,
a neonatologist would conduct a careful physical exami-
nation. The examination included heart rate, respiration,
muscle tension, body reflexes, skin color, facial indentation
or abrasion, scalp hematoma, clavicle fracture, and organ
dysplasia and then performed Apgar scores. At the same
time, the umbilical artery was taken for blood gas analysis to
comprehensively evaluate the condition of the newborn.
Assessment criteria for neonatal asphyxia: (1) mild asphyxia:
Apgar score 1 min ≤ 7, or 5 min ≤ 7, with umbilical artery
blood pH < 7.2, and (2) severe asphyxia: Apgar score
1 min ≤ 3 or 5 min ≤ 5, with umbilical artery blood pH < 7.0
[16]. The birth canal was examined by obstetricians and
midwives; if there was a laceration of the birth canal, it
needed to be sutured. In addition, as forceps midwifery was
one of the high-risk factors of postpartum hemorrhage, we
gave parturient prophylactic drug treatment to promote
uterine contraction immediately after shoulder delivery. If
postpartum hemorrhage occurred, the cause of the
5
hemorrhage should be identified quickly, then therapeutic
drugs, surgical hemostasis, and even blood products in-
fusion had to be carried out.
4. Traditional Management Scheme of
Forceps Delivery
Before implementation of forceps, the delivery process and
related auxiliary examination should be checked by the
senior physician. After learning fetal head station, fetal
position, auricle direction by vaginal examination, the senior
physician decided whether it is necessary to carry out forceps
delivery or not. Once forceps delivery was decided, the
senior physician implemented or instructed residents to
perform forceps delivery. The operations of forceps were the
same as the study group.
5. Observed Indicators
We evaluated the clinical effects of form-based forceps
management by the following indicators: success rate of
primary forceps traction, rate of perineal laceration, post-
partum hemorrhage, neonatal asphyxia, intracranial hem-
orrhage, and facial skin injury.
6. Statistical Analysis
The sociodemographic characteristics and delivery-related
data of the subjects were collected from the electronic case
system. We analyzed the skewness and kurtosis of the
patients’ clinical data. Normally distributed data such as
age, gestational age, and body mass index (BMI) were
expressed as mean ± standard deviation, nonnormally
distributed data such as gravidity and parity times were
expressed as median and interquartile spacing, and qual-
itative information was expressed as composition ratio. We
used an independent sample t-test to analyze the potential
statistical differences of age, gestational age, and BMI; used
Mann–Whitney U test to analyze the statistical differences
of gravidity, parity times, perineal laceration, and neonatal
asphyxia; and used the chi-square test to compare the
composition ratio between the two groups. The P value was
two-sided and the result was considered significantly dif-
ferent at P < 0.05. All the above-mentioned analyses were
carried out with SPSS software.
7. Results
7.1. Clinical Characteristics. During the period from January
1, 2017, to December 31, 2018, the number of forceps de-
liveries in our hospital was 626, while the number of cu-
mulative deliveries and vaginal deliveries was 44,601 and
24,593, respectively. From January 1, 2019, to December 31,
2020, there were 634 forceps deliveries, 42,409 total de-
liveries and 23,398 vaginal deliveries. The details are shown
in Table 3. Summary statistics of clinical data of the two
study groups are shown in Table 4, indicating little statistical
difference between the two groups.
6 Journal of Healthcare Engineering
Table 3: The status of vaginal deliveries and forceps deliveries during the last 4 years.
01/01/2017–31/12/2018
Total deliveries (case) 44601
Vaginal deliveries (case/rate) 24593 (55.14%)
Forceps deliveries (case/rate) 626 (2.55%)
Table 4: Descriptive statistics of basic information of study population.
Features Study group (n � 634)
Age (years) 29.33 ± 5.22
Gestational age (days) 273.29 ± 16.01
Gravidity (times) 2.00 (1.00–3.00)
Parity (times) 0.50 (0.00–1.00)
BMI (kg/m2) 25.79 ± 3.36
Data are presented as mean ± standard deviation or median (interquartile spacing). BMI: body mass index.
7.2. Maternal Outcomes. The success rate of forceps delivery
was 100% in both groups. All of the pregnant women in the
study group had successful one-time traction, while three
patients in the control group had failed in their first traction.
The main reason for failure was inaccurate forceps place-
ment due to fetal position error, and we had second-time
successful traction after repositioning forceps. Comparing
the success rate of disposable forceps traction between the
two groups, it was found that the success rate of the study
group was slightly higher than that of the control group,
although the differences were not obvious. The rates of
postpartum hemorrhage, second-degree perineal laceration,
and third-degree perineal laceration in the study group were
16.09%, 11.99%, and 0.32%, while those in the control group
were 24.92%, 18.85%, and 0.48%. It was found that the rate of
postpartum hemorrhage and the degree of perineal lacer-
ation in the study group were significantly lower than those
in the control group (Table 5).
7.3. Neonatal Outcomes. There were 634 newborns in the
study group, of which 7 had mild asphyxia and no severe
asphyxia. There were 626 newborns in the control group,
including 13 cases of mild asphyxia and 1 case of severe
asphyxia due to intracranial hemorrhage. There was no
significant difference in neonatal asphyxia between the two
groups. In the control group, one newborn had intracranial
hemorrhage. It was a case of a second traction after repo-
sitioning the forceps due to incorrect judgment of fetal
position, and the possible cause of intracranial hemorrhage
was considered to be excessive compression of the fetal head.
In addition, the incidence of facial skin injury was 3.94% in
the study group, which was significantly lower than that in
the control group (Table 6).
8. Discussion
Since 1996, with the improvement of cesarean delivery
techniques and the enhancement of pregnant women’s
awareness of safe delivery, the rate of cesarean section has
increased in both developed and developing countries, far
exceeding the alert level of the cesarean delivery rate set by
01/01/2019–31/12/2020 P value Method
42409
23398 (55.17%) 0.924 Pearson
634 (2.71%) 0.261 Pearson
Control group (n � 626) P value Method
28.40 ± 5.72 0.697 Independent sample t
270.00 ± 15.03 0.149 Independent sample t
3.00 (1.50–5.00) 0.28 Mann–Whitney
0.50 (0.00–1.50) 0.71 Mann–Whitney
25.74 ± 2.03 0.973 Independent sample t
the World Health Organization [17, 18]. However, the ce-
sarean section was not as safe as that we thought. In 2007,
a study from Canada showed that the risk of serious ma-
ternal illness was three times higher in patients who had
a cesarean section than in those who had a vaginal delivery
[19]. In the last 2 years, a number of studies had shown that
unnecessary cesarean sections increased maternal and
neonatal risks, even if it might increase maternal mortality
[15, 20]. In short, we believed that vaginal delivery was the
safer and more cost-effective way of delivery.
During the second stage of labor, when vaginal delivery
became difficult, forceps delivery was an important measure
to solve cephalic dystocia. Studies had shown that low
forceps or export forceps performed by experienced and
trained doctors in the second stage of labor might safely
reduce risks of cesarean delivery and that vaginal surgical
delivery should be considered a safe and acceptable alter-
native to cesarean delivery [12, 15, 21, 22]. However, forceps
delivery is highly required for obstetricians and midwifery; if
performed improperly, it might cause serious birth canal
injuries, postpartum hemorrhage, neonatal birth injuries,
and other complications. All of the complications would do
great harm to the mother and the infant. Therefore, we
needed to try to avoid complications.
In 2016, our hospital improved the traction method of
Kielland forceps which was consistent with the previously
described method. We found that the improved method
could reduce the complications of forceps delivery to some
extent, but because these technical improvements relied
more on the experience of operating physician, and a study
showed that the probability of error in judgment of fetal
position and parameters was 50%–80% for residents and
36%–80% for attending physicians [23]; therefore, the results
we achieved were not significant. Subsequently, we carefully
analyzed cases of forceps delivery that had serious com-
plications before January 1, 2019, and we found the main
causes of these complications were incomplete preoperative
assessment and improper operation, while the underlying
cause was the lack of standardized management of forceps
delivery.
The workload of the medical staff in the delivery room
was heavy. In order to remind the medical staff to pay
Journal of Healthcare Engineering 7

Table 5: Maternal outcomes of study population.

Study group (n � 634) Control group (n � 626) P value Method
Successful one-time traction (case/rate) 634 (100%) 623 (99.52%) 0.122 Fisher’s exact
Postpartum hemorrhage (case/rate) 102 (16.09%) 156 (24.92%) <0.001 Pearson
Perineal laceration
Second degree (case/rate) 76 (11.99%) 118 (18.85%)
0.001 Mann–Whitney
Third degree (case/rate) 2 (0.32%) 3 (0.48%)

Table 6: Newborn outcomes of study population.

Study group (n � 634) Control group (n � 626) P value Method
Neonatal asphyxia
Mild asphyxia (case/rate) 7 (1.10%) 13 (2.08%)
0.116 Mann–Whitney
Severe asphyxia (case/rate) 0 (0) 1 (0.16%)
Intracranial hemorrhage (case/rate) 0 (0) 1 (0.16%) 0.497 Fisher’s exact
Facial skin injury (case/rate) 25 (3.94%) 82 (13.10%) <0.001 Pearson

attention to the surgical risk of each forceps delivery, we
have changed our traditional forceps delivery protocol and
have been using a form-based forceps delivery management
protocol since 2019. We established a delivery safety
checklist and a forceps delivery checklist. The forceps de-
livery checklist was described in detail according to four
parts: preoperative verification, preoperative preparation,
intraoperative operation, and postoperative examination.
Specific verification requirements were put forward from
aspects of prerequisites of forceps midwifery, communica-
tion, personnel and facility preparation, key points of op-
eration, examination of postoperative maternal and fetal
complications, and so forth. At the same time, senior
physicians, residents, and midwives were required to par-
ticipate in and independently verify the key steps in the
process. In this way, we could avoid not only the omission of
preparations by medical staff due to fatigue, negligence, and
emergency but also incorrect operations due to inexperience
and so forth. In addition, we also emphasized the post-
operative verification of maternal and infant complications,
identified the causes of complications timely, and correct
errors early. Through this way, we could improve the forceps
delivery continuously.
After carefully checked by senior doctors, residents, and
midwives before the forceps delivery, the fetal positions of all
fetuses among 634 patients in the study group were accu-
rately judged and the traction was successful at one time.
While verification of fetus in the control group only relied on
senior doctors, there were three failed tractions at one time
due to errors in judging the fetal position, caused by neg-
ligence, fatigue, or tension of senior doctors. Also, the in-
cidence of perineal lacerations, postpartum hemorrhage, and
neonatal facial skin damage were significantly lower than
those of the control group based on no difference in neonatal
asphyxia. All of these fully demonstrated that the form-based
management of forceps delivery could strengthen co-
operation between doctors and midwives, help medical staff
comprehensively, and accurately evaluate the necessity and
operating conditions of the forceps delivery, aimed to avoid
errors in forceps operation and reduce complications of
mother and neonates. At the same time, it might not delay
the delivery of high-risk newborns. Therefore, form-based
management of forceps delivery was beneficial to obstetric
forceps management.
9. Conclusions
In this paper, we found that the form-based forceps delivery
management could improve the success rate of the one-time
forceps traction scheme and reduce the maternal rate of
postpartum hemorrhage and risk of perineal laceration
under the intelligent medical model. In the context of
promoting vaginal delivery and reducing the rate of first
cesarean delivery, we need to improve the skill level of
obstetric medical staff in forceps delivery and strengthen the
management of forceps delivery in the department and
homogenize the forceps delivery.
Data Availability
The datasets used and/or analyzed during the current study
are available from the corresponding author on reasonable
request.
Ethical Approval
The present study followed the tenets of the Helsinki
Declaration . Ethics approval was obtained from the In-
stitutional Review Board of Maternal and Child Health
Hospital Affiliated to Nanchang University in China.
Consent
Each participating woman gave informed consent.
Conflicts of Interest
The authors have declared that no potential conflicts of
interest exist.
8 Journal of Healthcare Engineering
Authors’ Contributions
Siming Xin and Zhizhong Wang contributed equally to this
work.
Acknowledgments
This work was financially supported by the Science and
Technology Project of Jiangxi Province (nos.
20192BBGL70003 and 20203BBGL73130) and the Science
and Technology Project of Jiangxi Provincial Health
Commission (No. 20195475). All authors are grateful to the
patients and the IT department who participated in this
study.
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